The effect of transferrin saturation on the estimation of erythropoietin by the mouse spleen cell microassay.

The effect of transferrin from various sources and the degree of saturation with iron on the stimulation of DNA synthesis by erythropoietin (Epo) has been investigated. Mouse, human, and bovine transferrins saturated with iron caused an increase in thymidine incorporation both in the absence and presence of Epo. In contrast, exogenous human and bovine apotransferrin resulted in significantly decreased incorporation of the tracer. The iron saturation of serum alters its apparent erythropoietic activity. This transferrin saturation effect may be overcome by a simple modification involving the addition of iron to the culture medium.

Dermatologic lesions in a transplant population.

Many authors have reported an increase in the incidence of skin neoplasia in renal transplant patients. Two hundred and twenty-three patients, who received a renal transplants between 1965 and 1984, were examined for the presence of skin lesions. There was a high incidence of simple warts (24%) and hyperkeratoses (21%). Frank malignancy had developed in 9 patients; this is more than 4 times the expected incidence for the population of Northern Ireland.

Increased incidence of IgM class smooth muscle antibody in patients after renal transplantation.

Autoantibodies were examined in 70 patients with renal failure, before acceptance on a hemodialysis program, during the program, and up to 3 months after renal transplantation. Smooth muscle antibody (SMA) in the IgM class was detected in 76% of the patients after transplantation compared with 14% before transplantation. This increase was significant at the 5% level. Furthermore, two groups of patients were distinguished on the basis of a 4-fold or greater increase or no demonstrable increase in the titer of IgM SMA after transplantation. Rejection episodes occurred more frequently amongst patients from this former group (67%) compared with the latter group (35%).

The influence of HLA-A, B, and DR matching on graft survival in primary cadaveric renal transplantation in Belfast.

HLA-DR matching has been shown in a retrospective study of 72 renal transplant patients to significantly enhance graft survival at 12 months. HLA-A and -B antigen matching also increased the graft survival rate significantly. Analysis of combined HLA-A, -B and -DR matching suggested an improvement in graft survival rate with better matching, but this did not attain statistical significance. It is now our policy to use HLA-DR matching prospectively and to ensure that all recipients receive a kidney with a maximum of 1 HLA-DR incompatibility and a minimum of 2 HLA-A and -B antigens shared.

Advantages of low dose steroid from the day after renal transplantation.

We have used a low dose of steroid (20 mg of prednisolone), commencing the day after transplantation, for 151 consecutive renal transplants in 141 patients. Five patients received grafts from living related donors, 146 received cadaver grafts. All patients received azathioprine for routine immunosuppression and the first 47 received a single dose of actinomycin C i.v. for treatment of rejection. No other immunosuppressive drugs were used. This treatment provided satisfactory immunosuppression as 109 of 151 grafts continue to function for periods of 3 months to 10 years and, of 42 grafts lost, only 17 failed from rejection. The cumulative survival of first cadaver grafts at 1 and 2 years in recipients of all ages (7 to 55 years) was 77.9 and 76.0%, respectively; in recipients 15 to 34 years old, 90.9 and 86.1%, respectively. Twenty-three patients died, no patient died from infection during the admission for transplantation, and infection played a part in the deaths of only four patients. The incidence of other complications was low; seven patients developed gastrointestinal complications, one died, four patients developed diabetes, all survived; only one patient developed avascular necrosis of bone.

Increased plasma glycosidase and protease activity in uraemia: possible role in the aetiology of the anaemia of chronic renal failure.

We have measured plasma N-acetyl-beta-D-glucosaminidase (EC 3.2.1.30) and neuraminidase (EC 3.2.1.18) activities as markers of glycosidase activity and immunoreactive trypsin (EC 3.4.21.4) levels as a marker of proteolytic potential in the plasma of normal and uraemic subjects. The levels of all of these enzymes are significantly elevated in the plasma of uraemic subjects when compared to normal. We have postulated that the combined attack of glycosidases and proteases on erythropoietin will lead to fragmentation of this glycoprotein hormone with loss of activity. This may be a major contributory cause to the anaemia of chronic renal failure.

Reflux nephropathy as a cause of end-stage renal failure.

Reflux nephropathy can present as end-stage renal failure in adults without previous history of urinary infection. We describe four cases to illustrate this and suggest that in cases of end-stage renal failure with bilateral small kidneys a micturating cystogram should be performed prior to transplantation.

Mismatching for HLA-A, -B antigens and renal graft survival.

One hundred and seventy five recipients of a kidney graft were analyzed to see if mismatching for certain HLA-A, -B antigens was detrimental to graft survival. No association was found between graft survival and a specific mismatched HLA-A, -B antigen.

Pre-transplantation immunological monitoring and graft survival in recipients of renal allografts.

Various immunological parameters were measured pre-transplantation in 82 renal transplant recipients. The results were compared with the clinical course of the recipient post-transplantation and with the results of 40 controls. Only one test C3 inactivation products (C3i) was associated with transplant outcome in that 0/30 patients with no rejection episodes had C3i whereas 9/38 patients with rejection episodes, including 3/12 patients whose graft failed, had C3i.

Isotope renography and long term follow-up of renal transplant patients.

Isotope renography was carried out in 64 kidney transplant patients attending a follow-up clinic. Graft survival in these patients ranged from two months to ten years. Forty-one patients had normal renograms and 98% of these had satisfactory function (creatinine clearance greater than 50 ml/min). Eighteen patients showed a major renogram abnormality and 50% of these had impaired function. Five of these 18 have been explored and found to have graft complications (obstructive disease in four, chronic pyelonephritis in one). Exploration has not been undertaken in the remaining 13 but nine show evidence suggestive of graft pathology (proteinuria, impaired creatinine clearance, elevated urinary enzymes, calyceal distortion on IVP). A successful kidney transplant should result in a normal isotope renogram, and a major abnormality of the renogram suggests the presence of a graft complication, even when the creatinine clearance is unimpaired. We feel renography is useful for identification of renal transplant patients who require further investigation or closer follow-up.

Gastric function in primary hyperparathyroidism in man.

1. GASTRIC function was studied pre-operatively in 55 patients with primary hyperparathyroidism. In all patients the diagnosis of hyperparathyroidism was proved by the removal of an enlarged parathyroid gland or glands, following which the serum calcium fell to normal or below. 2. Twenty patients (38 per cent) gave a history of dyspepsia. All patients were given a barium meal and 12 (22 per cent) were found to have a duodenal ulcer. Male patients had dyspepsia and/or an ulcer more frequently than female patients. 3. Kay's augmented histamine test was carried out in all patients. Six patients (11 per cent) had achlorhydria, six had hyperchlorhydria (11 per cent), the remaining patients secreting normal amounts of acid. The acid secretion did not differ significantly from that of a group of euparathyroid patients studied under similar circumstances who did not have duodenal ulcer on barium meal. 4. Antigastric-parietal-cell antibodies and antithyroid antibodies were absent in all 20 patients, including five with achlorhydria, tested. 5. Serum gastrin was slightly elevated in three out of 10 patients preoperatively, and there was no consistent change following parathyroidectomy. 6. Although there is a high incidence of dyspepsia and of duodenal ulcer in patients with primary hyperparathyroidism they do not tend to have increased acid secretion.

Outcome of pregnancy following renal transplantation.

Successful renal transplantation improves fertility with 1 in 50 women of childbearing age becoming pregnant. Pregnancy following renal transplantation is associated with increased maternal and fetal complications. In Belfast 118 women of childbearing age (15-45 yrs) have received a renal allograft and of these 14 (12%) have become pregnant. Twenty-seven pregnancies have resulted in 23 live births (including one set of identical twins), 1 still birth and 4 first trimester abortions. The most frequent complications were hypertension and prematurity. In this group of patients, whose sole immunosuppressive therapy was azathioprine and prednisolone, pregnancy post transplantation was associated with frequent successful outcome and a low incidence of maternal and fetal complications.

Live donor renal transplantation--the experience of the Belfast Renal Unit.

Live donor renal transplants are often preferred to cadaver grafts because of better graft survival. In a retrospective study of 41 live donor transplants performed in the Belfast Renal Unit from 1971 until November 1988, actual graft survival at 2 and 5 years was 84% and 69% respectively. Corresponding patient survival rates were 87% and 81%. These results are no better than those of cadaver grafts. A subdivision of patients considered to be relatively poor risk for transplantation showed less favourable results than those who were good risk. 15% of the donors suffered post-operative complications, which occurred more often in older donors. Live donor transplantation is not necessarily preferable to cadaver organ graft, and is not recommended for poor risk recipients or donors aged over 50 years.

Prevalence of advanced renal failure in Northern Ireland.

OBJECTIVE: To determine the prevalence of advanced chronic renal failure in Northern Ireland as part of an assessment by the Renal Association of the level of service provision for treatment of such patients. DESIGN: Prospective notification of patients reaching a defined level of advanced chronic renal failure (serum creatinine concentration greater than or equal to 500 mumol/l or blood urea concentration greater than or equal to 25 mmol/l) within one year and follow up for at least three, and, at most, four years after notification. SETTING: Northern Ireland. PATIENTS: 122 Patients with a serum creatinine or blood urea concentration higher than the defined level newly detected from 1 March 1985 to 28 February 1986. MAIN OUTCOME MEASURE: Survival after notification. RESULTS: 77 Patients of all ages/million population/year had advanced chronic renal failure compared with 67/million/year between the ages of 5 and 80 found in an earlier study of the same population. 62% Of the patients were older than 50 years. Seventeen (14%) of the patients either required dialysis or died within one month of notification, 51 (42%) survived for at least three months, and 23 (19%) for one year or longer. Three patients, all of whom were attending a renal clinic, survived for periods of 43, 45, and 46 months respectively without renal replacement treatment. CONCLUSIONS: The increased number of new patients disclosed in this survey compared with the earlier survey is mainly owing to an increased number of older patients. Such patients often have disabilities other than renal failure, are less likely to be capable of self treatment, may develop complications more often and require more frequent hospital admissions, and may not be suitable for transplantation and consequently have considerable resource implications for the NHS.

Renal replacement treatment for diabetic nephropathy in Northern Ireland 1979-1987.

Twenty-three patients with end-stage renal failure due to diabetic nephropathy received renal replacement treatment. All patients had insulin-dependent diabetes mellitus. Nineteen transplants were performed in seventeen patients. Two-year graft survival for all transplants was 74% with a two-year patient survival post-transplantation of 81%. Overall two-year patient survival was 73%, compared with 82% in non-diabetic patients receiving renal replacement treatment. In diabetic patients accepted for treatment there was a high incidence of non-renal complications, particularly vascular disease. An aggressive approach to the treatment of vascular disease in these patients may improve overall survival rates.

The treatment of urinary tract infection.

Urinary infections are due to organisms gaining entry from the genital area and are therefore much commoner in females than in males. In male patients of any age urinary infection is often associated with some underlying abnormality and warrants full investigation. Recurrent infections in girl children may lead to renal scarring and later impairment of function and require careful management. Occult infections occur. The majority of patients with urinary symptoms are adult women, and symptoms tend to recur. These can produce great distress but in this age-group they do not lead to renal scarring. When symptoms occur for the first time during pregnancy they are associated with a high prevalence of underlying radiological abnormalities and should be investigated after the pregnancy. Care should be taken to ensure that apparent uprinary symptoms due to other causes are not mistakenly treated with antibiotics. The immediate management of patients with urinary symptoms consists in relief of discomfort, combined with treatment by an antibacterial drug appropriate for the infecting organism. The urine culture should be repeated after the course of treatment. Simple measures can prevent or reduce recurrences in adult women.